- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,324.53 / $1,324.53 / $1,324.53
| Facility | | $1,324.53 | $1,324.53 | $1,324.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.53 / $1,324.53 / $1,324.53
| Professional | | $1,324.53 | $1,324.53 | $1,324.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.00 / $1,332.00 / $1,698.70
| Professional | | $1,332.00 | $1,332.00 | $1,698.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $1,133.51 / $1,133.51
| Professional | | $1,133.51 | $1,133.51 | $1,133.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.22 / $1,615.22 / $4,932.79
| Professional | | $1,615.22 | $1,615.22 | $4,932.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.48 / $1,119.35 / $1,756.27
| Professional | | $826.48 | $1,119.35 | $1,756.27 |